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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------------- Permit No. <br /> (Complete in Triplicate) <br /> ---------------- ---------------------------- <br /> __-""--_- This Permit Expires i Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> r <br /> JOB ADDRESS/LOCATION ' <br /> CENSUS TRACT _________________________ <br /> .--__ '� - ^j'--- <br /> Owner's Name -- , ------- ------------ ----------- -f• ------------------Phone ------------------ <br /> -----------....-- <br /> Z' e, ' ------------------------- -•--- City + - ------------------------------------------ <br /> Address <br /> �l W-O <br /> Contractor's Name ------ ---- ^' Q/ •-"------------------------------License #o If-_ _ Phone + �2�'�--- <br /> Installation will serve: ResidenceX Apartment House❑ Commercial ❑Troller Court 0 <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units..-.Z------ Number of bedrooms __fir----.-Garbage Grinder /�.G�_-_ Lot Size pk- ®-/--•---------- <br /> Water Supply: Public System and name -_CQ /`-_.lt�ft �`----►��.C� ------------------------------------••_Prlva#e ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeX Fill Material ------------ If yes,type ---___________------____ <br /> (Piot plan, showing size of lot, location of system .in relation to wells, buildings, etc.=must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size------------------------------------------------ Liquid Depth ------------------------- <br /> Capacity --- ----- ------ Type ------------------- Material--------- ------------ No. Compartments -----------•-•------- <br /> Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. Line -------------------•--� <br /> LEACHING LINE No. of Lines .-_-____.__ Length of each line------------- Total Length 0 <br /> f- : r <br /> 'D' Box ---------'*'Type Filter Material ____________________Depth Filter Material ---------------------------------------------r <br /> Distance to nearest: Well ------------------------ Foundation ----------- -------_--- Property Line ------------------------ <br /> TO <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter -------------._. Number 4______.--- .---,----------- Rock Filled Yes ❑ No c <br /> Water 'liable Depth ------------------------- <br /> -----------------------Rock Size -------------------------------- <br /> 1%lance to nearest: Well ----------------------------------- Foundation -------------------- Prop. Line --------.----------___ <br /> REPAIR/ADDITION IPrev. Sanitation Permit# -------------------------------------------- Date ----------------------------------- <br /> Septic Tank (Specify Requirements) --------------- ------------- ------------------------------------------- ------------------------------ ----- -------- <br /> -------------- <br /> Disposal Field (Specify Requirements) <br /> -------- <br /> ------------------------------------------------------------- <br /> --------------------------- ------------------ -------------------------------------------------------- <br /> ------------------------- - <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or f licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------- -- ---------------- ------------------------------------------------- Owner <br /> BY ------------- ------- <br /> � - ._ -------- Title _ if =l �� <br /> jif other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- -- -------------- � DATE <br /> ;y DATE .. --------- <br /> BUILDING PERMIT ISSUED ---------------------" <br /> ---- <br /> ADDITIONALCOMMENTS ----------------- ------------------- -----•--------------------------------------------------------------------------- ---------- <br /> --------------------------------------------- --------------------------------------- --------- <br /> ----------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------- ------------------------- ------------------------------------------ <br /> -------------------------------- 3 f Vit-f <br /> - - - - - ----- <br /> ---------------------------- --------------------------- ---------------------- -------------- --------- -- <br /> Final Inspection by: <br /> ._Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />